There are many disturbing flashbacks of a mother having a miscarriage, and the camera focuses greatly on her blood-covered swollen belly. We see the father being very violent with her in this state as well.
There are several scenes of extreme violence involving gunshots and stabbing, and copious amounts of blood splatter. The effects used to produce these are very realistically done and are shot very intensely, not at all 'cheesy' or 'campy'-- the overall effect being very frightening.
Also there is much violence done between sisters. Some of this verges on abuse and some is more straightforward vicious behavior. This film is about a very dysfunctional family, and executed with such verisimilitude that one feels like one is watching the most horrifying reality show imaginable.